Referral Form

To refer a client to UHHR please complete this form and we follow up with you within two-three business days. 

Today's Date:

Agency or Provider:

Name of person making referral:

Patient/Client Name:
Client Phone:

Date of Birth:


Is client being helped by: 

Client Address:

Country of Origin:

Year of Initial Violence:
  Type of traumatic exposure:

  Personal History of:

Violence perpetrated by:

Current Syptoms:

Other Information: